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Home My Public Portal About9726 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE876(1h-84) MISCELLANEOUSp-PPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES UILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN ILDING ADDRESS �`•� Certified copy is hereby furnished. nnoeess LOCALITY �� ` � ❑ Certified copy is filed with the county building inspection LOCALITY cross sT dr department. . Date Applicant NEAREST DISTRICT NO. G OUP TYPE P OCE SSED BY CROSS ST. �D O � GONST� CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL o y COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY O. F BLDGS. STATE MAJOR SECOND LOCAL NO. (CIRCLE) N (This section need not be completed if the work involved TRACT NOWOON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) uSH of SIZE OF LOT EXISTING BLDG. d I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner FOWNER d =' so as to become ubject tc the I orke ' ompensation Laws. MAIL OCCUPANCY GROUP o Date h nt ADDRESS )C tv PP NOTICE 0 AP ICAN . If,after making this rtificate of clry no� OCCUPANT LOAD Exemption, you should become subject to a Workers' APPLICATION F R EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ deemed revoked. ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No. of EXITS ness and Professions Code,and my license is in full force and p effect. 0� S/ CS�' PARKING REO'D PROVIDED ,�c% SPACES License Number Lic. Class C �' ��GLIMITED TIME U S E Contractor Date o DATE DATE EJI am exempt from the licensing requirements as I am a PROMI TO: licensed architect or a registered profbssional engineerSIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING HLD G. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL ' PRESENT USE OF BUILDING - Cf /'� Lic.or Reg.No. Date / � � HOME OWNER-BUILDER DECLARATION NO. OF EXISTING UILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING ��1 s1t- 1 I•MU 1L. I, as owner of the property, will do the work and the SPACES PROVIDED a structure is not intended or offered for sale (Section (/- 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 09 upon the*betmVentiond property for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE mittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N EO U S APPLICATION •I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,e,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APP LI CANT TO FILL IN BUILDING 5G ADDRESS f ❑ Certified copy is hereby furnished. ABU ILDING DDRESS I / LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST / DISTRICT NO. OUP TYPE CONST. MESSED BY Lz CROSS ST. f0/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK 14 A (HIHWAY CCR LE) STATE MAJOR SECOND LOCAL NO. OF BLOGS. (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. �•� I certify that in the performance of the work for which this Ci permit is issued,I shall not employ any person in any manner OWNER II =' so as to become subject to the Workers' Compensation Laws MAIL 4� OCCUPANCY GROUP. 1 o Date Applicant AD°KESS LLI NOTICE TO APPLICANT: If, after making this Certificate of CITY �yT TN l OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI A N FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. KnowL El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices 0 I hereby affirm that I am licensed under provisions of Chapter SAFETY PERM. ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi No. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING SPACES REQ,D PROVID BD License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE F-1I am exempt from the licensing requirements as I am a FRO": O: licensed architect or a registered professional engineer SIZE OF NO.OR INSPECTOR'S acting in my professional capacity (Section 7051, Bus- iness us ? . EXISTING BLDG. STORIES SIG ATURE inessandProfessionsCode). �q PRESENT USE OF BUILDING FINAL APPROVAL Lic.or Reg.No. Date l-1�1�,rS ��01�1•- � - • F HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BIALDINGS ON LOT AND USE -- I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING _ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING IVI hereby affirm that there is a construction lending agency for the performance of the work for which this permit is a rQ issued(Sec.3097,Civ.C.). Lender's Name l PROPOSED MAX. OCC. Lender's Address ,� Q I certify that I have read this application and state that the PERMIT FEE 5DO- above information is correct.I agree to comply with all County ISSUANCE FEE ordinances an tate laws relating to building cons-•aC on, sand hereby horize represent ives of thiy gunt�T ses.ter TOTAL FEE U u n he a mentio d pro resent: for ii1S(i!:� i'w... SEE REVERSE FOR EXPLANATORY LANGUAGE I FW Signature of Permittee /A Date